June 24, 2009— -- The following is a transcript from ABC News' health care forum, "Questions for the President: Prescription for America" on June 24, 2009, in the East Room of the White House.
ANNOUNCER: From the White House, a special edition of "Primetime."
OBAMA: We have finally decided to fix what's broken about health
care in America.
ANNOUNCER: The president calls for sweeping reforms. What the
changes would mean to your family.
(UNKNOWN): What's going to happen if my cancer comes back?
ANNOUNCER: Who decides what doctors you can see and the treatment
(UNKNOWN): Who should decide whether you live or die? The government?
ANNOUNCER: And how much are we willing to pay? Real people, real
fears, and tonight, real answers.
OBAMA: We need to get this done.
ANNOUNCER: Questions for the president, prescription for America.
Now, from White House, Charles Gibson and Diane Sawyer.
(END VIDEO CLIP)
GIBSON: Good evening. Diane and I are delighted that you could
join us this evening. We are going to be talking about what will be the
number one subject for public discourse all through this summer, and
that is health care reform.
SAWYER: The president has said it's the ticking time bomb at the
center of the American economy, and so we have gathered 164 people in
the East Room of the White House tonight. They're from all over the
country, all walks of life, on the front lines of health care in
America. They are doctors, businessmen, patients, Republicans,
Democrats, independents. And we know we can't cover every question
tonight, but we're going to get the conversation started.
GIBSON: They will be questioning the president, as will we. And we
think by the end of the evening, you will have a pretty good sense of
what the parameters of this debate are, just what's at stake for each of
you and for the country as a whole, because this will be discussed, as
we said, all through the summer in the Congress. It will be discussed,
I think, also in your living room. Every family, I think, will be
So with that as preface, we want to thank the president for giving
us his parlor and his living room tonight to do this broadcast.
OBAMA: Thank you so much, Charlie.
GIBSON: Mr. President, I think this could be an interesting evening.
OBAMA: Thank you so much, Diane.
SAWYER: Mr. President, thank you.
OBAMA: Grateful to have you.
SAWYER: And while we head into the East Room, we're going to have
the audience waiting for us there. Dr. Tim Johnson, who's our medical
editor, is going to give everyone a sense of some the key questions.
We're heading to the East Room.
DR. TIMOTHY JOHNSON: First: access and choice. The president constantly
stresses that, if you like what you have, you can keep it. But he also
wants to offer more choice and competition with a one-stop shopping list
of approved private insurance plans through a so-called health insurance
So far, he has also insisted that a public option be one of the
choices. It has sometimes been described as Medicare like, meaning the
government would be involved with the financing, but patients would be
able to choose their own doctors and hospitals.
He says this public option would keep pressure on private insurance
to hold down costs. Critics say government's advantages -- easy
funding, huge bargaining power -- would eventually put private insurers
out of business, which could affect your current coverage.
Second: effective treatment. The president agrees with experts who
say that about a third of what we now spend on health care is
unnecessary. He says we reward doctors and hospitals the wrong way,
paying for simply doing more tests and procedures, rather than paying
for good outcomes.
And he stresses that primary care, readily available family doctors,
physician assistants and nurse practitioners is essential in promoting
prevention, making sure we get screening tests and lifestyle advice, and
coordination, orchestrating the care of specialists and home care for
Critics say that, if third-party government experts set the rules
for what is covered and paid for, patients and doctors will have less of
a voice and choice.
And, finally, cost control. The president insists that increasing
coverage without controlling costs is a formula for economic disaster.
That will be a tough job, given that estimates for reform now run
between $1 trillion and $2 trillion over 10 years.
Besides savings from the reform of Medicare and Medicaid, he has
advocated new tax revenue by limiting deductions for charitable giving,
but he has not yet agreed to taxing any insurance benefits from
employers as income. Critics say his plan spends too much and the
government just does not have the money.
So, Diane and Charlie, three huge challenges, a formula for
heartburn, which, by the way, is something we doctors can fix.
GIBSON: Dr. Tim Johnson there outlining some of the parameters of
the debate. And we're going to try to loosely organize things. We have
this -- we're calling this prescription of America, but basically this
is, how does this affect me? How does it affect all of you at the
doctor's office? Should there be a public option, public -- government
insurance in all of this? And what is the cost of all of this? Can we
And as we mentioned, 164 people here from all walks of life, Mr.
President. Before we start, I'm curious. I want to get a show of
hands. How many of you -- whether you agree with the president's
approach or not, how many of you agree that we need to change the health
care system in America?
And is there anybody here who believes the system should be left
Interesting. But there is a lot of disagreement, because the devil
is in the details, as we all know.
OBAMA: Let's -- let's stop now.
OBAMA: Let's go. We're ready to...
GIBSON: So, as we say, all of this is, how does this affect me?
And we want to get your questions.
And I want to start with Dr. Orrin Devinsky. Is he here? Dr.
DR. ORRIN DEVINSKY, EPILEPSY SPECIALIST: Yes, in the past, politicians who have sought to reform health care have tried to limit costs by reducing
tests, access to specialists, but they've not been good at taking their
own medicine. When they or their family members get sick, they often
get extremely expensive evaluations and expert care.
If a national health plan was approved and your family participated,
and, President Obama, if your wife or your doctor became seriously ill,
and things were not going well, and the plan physicians told you they
were doing everything that reasonably could be done, and you sought out
opinions from some medical leaders and major centers, and they said
there's another option that you should -- should pursue, but it was not
covered in the plan, would you potentially sacrifice the health of your
family for the greater good of insuring millions? Or would you do
everything you possibly could as a father and husband to get the best
health care and outcome for your family?
OBAMA: Well, first of all, Doctor, I think it's a terrific
question, and it's something that touches us all personally, especially
when you start talking about end-of-life care.
As some of you know, my grandmother recently passed away, which was
a very painful thing for me. She's somebody who helped raise me.
But she's somebody who contracted what was diagnosed as terminal
cancer. There was unanimity about that. They expected that she'd have
six to nine months to live. She fell and broke her hip. And then the
question was, does she get hip replacement surgery, even though she was
fragile enough that they weren't sure how long she would last, whether
she could get through the surgery.
I think families all across America are going through decisions like
that all the time. And you're absolutely right that, if it's my family
member, it's my wife, if it's my children, if it's my grandmother, I
always want them to get the very best care.
But here's the problem that we have in our current health care
system, is that there is a whole bunch of care that's being provided
that every study, every bit of evidence that we have indicates may not
be making us healthier.
GIBSON: But you don't know what that test is.
OBAMA: Well, oftentimes we do, though. There are going to be
situations where there are going to be disagreements among experts, but
often times we do know what makes sense and what doesn't. And this is
just one aspect of what is a broader issue.
And if I could just pull back just for a second, understand that the
status quo is untenable, which is why you saw -- even though we've got
Republicans, Democrats, independents, people from all parts of the
health care sector represented here, everybody understands we can't keep
doing what we're doing.
It is bankrupting families. I get letters every single day from
people who have worked hard and don't have health insurance.
It is bankrupting businesses who are frustrated that they can't
provide the same kind of insurance that they used to provide to their
employees. And it's bankrupting our government at the state and federal
So we know things are going to have to change. One aspect of it,
the doctor identified, is, can we come up with ways that don't prevent
people from getting the care they need, but also make sure that because
of all kinds of skewed incentives, we are getting a lot of quantity of
care, but we're not getting the kind of quality that we need.
SAWYER: I want to ask about this, Mr. President, because you said
to me when we talked yesterday that you think if everyone has the right
information, that doctors will make the right decisions, patients will
make the right decisions. And you just said we think we do know what is
And Dr. John Corboy from Colorado, do we always know? And what
if a patient comes to you and says, no, I want that extra CT-scan, I
think I need that extra CT-scan, and you're at the risk of being sued,
among other things, what are you going to do?
DR. JOHN CORBOY, NEUROLOGIST & MEDICAL PROFESSOR: Well, I think you still have to provide the appropriate care. And I think we all know that there is a significant amount of care that actually is inappropriate and unnecessary.
And the question then is -- for you, Mr. President, is, what can you
convince -- what can you do to convince the American public that there
actually are limits to what we can pay for with our American health care
And if there are going to be limits, who is going to design the
system and who is going to enforce the rules for a system like that?
OBAMA: Well, you're asking the right question. And let me say,
first of all, this is not an easy problem. If it was easy, it would
have been solved a long time ago, because we've talking about this for
decades, since Harry Truman.
We've been talking about how do we provide care that is
high-quality, gives people choices, and how can we come up with a
uniquely American plan? Because one of the ideological debates that I
think has prevented us from making progress is some people say this is
socialized medicine, others say we need a completely free market system.
We need to come up with something that is uniquely American. Now
what I've said is that if we are smart, we should be able to design a
system in which people still have choices of doctors and choices of
plans that makes sure that the necessary treatment is provided but we
don't have a huge amount of waste in the system. That we are providing
adequate coverage for all people, and that we are driving down costs
over the long term.
If we don't drive down costs, then we're not going to be able to
achieve all of those other things. And I think that on the issue that
has already been raised by the two doctors, the issue of evidence-based
care, I have great confidence that doctors are going to always want to
do the right thing for their patients, if they've got good information,
and if their payment incentives are not such that it actually costs them
money to provide the appropriate care.
And right now, what we have is a situation, because doctors are paid
fee-for-service, and there are all sorts of rules governing how they
operate, as a consequence often times it is harder for them, more
expensive for them, to do what is appropriate.
And we should change those incentive structures.
GIBSON: And people, I think, understand that you want to get away
from quantity for quantity's sake, because that's the way the doctor
makes more money, and get to quality.
But the question is, how do you do that? How do you get to the
point and still assure people, as both of the doctors have asked, that
their cousins, their nephews, their husbands, their wives, are going to
get everything that is necessary?
OBAMA: Well, let's take an example. And I -- they may be
represented here, I wasn't sure, but the Mayo Clinic, everybody has
heard of it. It has got some of the best quality care in the world.
People fly from all over the world to Rochester, Minnesota, in order to
get outstanding care. It turns out that Mayo Clinic oftentimes provides
care that is as much as one-third less expensive than the average that's
provided or -- or some other health care systems that aren't doing as
good of a job. Now, why is that?
Well, part of it is that they have set up teams that work together
so that, if you go first to your primary care physician and they order a
test, you don't then have to duplicate having two more tests with other
specialists, because they were in the room when you first met with that
primary care physician.
They know how to manage chronic diseases in an effective way so that
we have people who are getting regular checkups, if they're trying to
manage diabetes, as opposed to us paying for a $30,000 foot amputation
because we didn't manage the disease properly.
So they are doing all kinds of smart things that we could easily
duplicate across the system, but we don't. And our job in this -- in
this summer and this fall, in which I think everybody understands we've
got to move in a different direction, is to identify the best ways to
achieve the best possible care in a way that controls costs and is
affordable for the American economy long term.
SAWYER: Mr. President, you mentioned the Mayo Clinic, and I'm going
to cross as I talk here, if you don't mind. But I've been reading a lot
of the e-mail questions that we've been getting online. They've been
saying the Mayo Clinic is exactly the point. They're doing it. Private
industry is doing it. Private hospitals are doing it. The Safeway
company is taking action.
Why get the government involved in something that is being done
already in the private sector and, with the right initiative and
impetus, could be done in the private sector without government involvement?
OBAMA: Well, you just said "with the right initiative." And,
unfortunately, that initiative hasn't been forthcoming. And as a
consequence, what's happening is -- here's what's happening to ordinary
families, because I know one of those boxes was, "How does this affect you?"
The average family has seen their premiums double in the last nine
years. Costs for families are going up three times faster than wages.
So if you're happy with your health care right now -- and many people
are happy with their health care right now -- the problem is, 10 years
from now, you're not going to be happy, because it's going to cost twice
as much or three times as much as it does right now.
Out-of-pocket expenses have gone up 62 percent. Businesses
increasingly are having to cut back on health care or -- and if you talk
to ordinary workers, they're seeing this all the time -- employers, even
if they don't want to, are having to pass on costs to others.
So -- so, unfortunately, whatever it is that we're doing right now
isn't working, Diane. What we see is great examples of outstanding
care, businesses that are working with their employees on prevention,
but it's not spreading through the system.
And, unfortunately, government, whether you like it or not, is going
to already be involved. You know, we pay for Medicare. We pay for
Medicaid. There are a whole host of rules both at the state and federal
level governing how health care is administered.
And so the key is for us to try to figure out, how do we take that
involvement, not to completely replace what we have, but to build on
what works and stop doing what doesn't work? And I think that we can do
that through a serious health care reform initiative.
GIBSON: But you say we have to figure out how to do that. Don't we
have to do that first, figure out so people have a good sense that my
medical care is going to be sufficient for me?
GIBSON: That's what people are afraid of...
GIBSON: ... that they're not going to get...
OBAMA: ... absolutely, people are afraid of it. People are
concerned -- they know that they're living with the devil, but the devil
they know they think may be better than the devil they don't. And --
and that's understandable.
Look, every time we've made progress in this country on health care,
there has been a vigorous debate. You know, senior citizens love Medicare now, but there was a big debate about whether we could set up Medicare. Children's Health Insurance Program, which provides millions of children health care across this country, that was a big debate.
So there's -- these things are always going to be toughpolitically. Let me tell you, though, that we actually do know in a lotof instances what works and what doesn't. What's lacking is notknowledge. We've been debating this stuff for decades.
What's lacking is political will, and that's what I'm hoping theAmerican people provide, because genuine change generally does not comefrom Washington. Whether we like it or not, it comes from the Americanpeople saying, "It's time for us to move forward." And I think this isthat moment.
SAWYER: And when we come back, Mr. President, from the break, we'regoing to be talking more about the centerpiece of this in many ways,primary care doctors and providers. And I'm going to turn to HershawDavis here, who's a nursing student and also an emergency tech atJohns Hopkins. Stand up, if you will, because how bad is our shortageout there?
HERSHAW DAVIS, NURSING STUDENT: It's bad, sir. Currently, our patient load isincreasing due to patients not having access either to insurance orprimary care. And I want to ask, what's the administration going to doto place primary care providers -- physicians and nurse practitioners --back in the community so the E.R. is not America's source of primary care?
SAWYER: All right.
GIBSON: Let's leave that question on the table.
SAWYER: On the table.
GIBSON: We'll give you a second to think about the answer, andwe'll take a commercial break. Be right back.
ANNOUNCER: Questions for the President, Prescription for Americacontinues. Once again, from the East Room of the White House, CharlesGibson and Diane Sawyer.
GIBSON: Mr. President, before we went to break, Hershaw Davis raised what is an elemental question, which is, any kind of new systemneeds to be built around primary care, and not all the specialists withall the tests, but primary care physicians who can then farm you out, ineffect.
So how do we reorient the system very quickly to get better primarycare and more primary care?
OBAMA: Well, first of all, we need more people like Hershaw,who are going to school and committed to the kind of primary care that'sgoing to be critical to us bringing down costs and improving quality. We're not going to be able to do it overnight. Obviously, trainingphysicians, training nurse practitioners, that takes years of work.
But what we can do immediately is start changing some of theincentives around what it takes to become a family physician. Rightnow, if you want to go into medicine, it is much more lucrative for youto go into a specialty. Now, we want terrific specialists, and one ofthe great things about the American medical system is we have wonderfulspecialists, and they do extraordinary work.
But increasingly, medical students are having to make decisionsbased on the fact that they're coming out with $200,000 worth of loans. And if they become a primary care physician, oftentimes they are goingto make substantially less money and it's going to be much harder forthem to repay their loans.
So what we've done in the recovery act, we've started by seeing ifwe could provide additional incentives for people who wanted to go intoprimary care. Some loan forgiveness programs, I think, are going to bevery important.
But what we're also going to have to do is start looking at Medicarereimbursements, Medicaid reimbursements, working with doctors, workingwith nurses to figure out, how can we incentivize quality of care, ateam approach to care that will help raise and elevate the profile offamily care physicians and nurses, as opposed to just the specialistswho are typically going to make more money if they're getting paidfee-for-service?
GIBSON: Is Mary Vigil in the room? Mary Vigil, there youare. You're a -- you're a medical student, right? Coming out -- andhow much debt will you -- can we get a microphone to Mary? How much debt...
GIBSON: How much debt will you have?
MARY VIGIL, MEDICAL STUDENT: I'll be in about $300,000 in medical education debt.
GIBSON: And you would -- you would like to go into primary care?
VIGIL: Definitely. That's -- that was my primary motivationin going in to medical school.
GIBSON: But you know you will be remunerated at a lesser level thana specialist?
OBAMA: Right. And so one of the things that we've got to figureout is how to change that calculation. Now, you may still go intoprimary care -- and I hope you do -- but I don't want to make it tougherfor you. I want to make it easier for you.
And one of the things that I'd like to explore -- and I've beenworking with the administration and with Congress is -- are there areloan forgiveness programs where people commit to a certain number ofyears of primary care. That reduces the costs for their medicaleducation. That would make a significant difference.
GIBSON: But let me ask a basic question, which may sound silly andnaive. But we've got 46 million people who are uninsured in this country.
GIBSON: And one of your goals, one of the goals of health carereform is to get those 46 million people insured.
GIBSON: We only have X number of doctors in the country. If youadd 46 million people to the insurance rolls, you can't get anappointment now, Mr. President. How are you going to get an appointmentthen, when there's 46 more million people competing for that doctor's time?
OBAMA: Well, this is going to be a significant issue. First ofall, I think it's important that, whatever we do, we're going to phaseit in. It's not going to happen overnight.
If we provide the right incentives, I think we're going to startseeing more young people say that going into medicine is a satisfying,fulfilling profession, especially if we can eliminate some of thepaperwork and bureaucracy that they have to deal with right now.
And I -- I have a lot of friends who are doctors, and they complainto me all the time about the administrative and business sides of thepractice when they actually got into medicine because they wanted toheal people.
But I also think that one of the big potential areas where we canmake progress is what Hershaw talked about, and that is, how can weget nurses involved in more effective ways?
If you look at what's happening in some states like Massachusetts,where they tried to create a universal system -- and they haven't quitegotten there yet -- they have had a problem with an overload of patients.
But one of the areas where we can potentially see some savings is, alot of those patients are being seen in the emergency room anyway. Andif we are increasing prevention, if we are increasing wellness programs,we're reducing the amount of emergency room care, then that frees updoctors and resources to provide the kind of primary care that will keeppeople healthier, but also allow them to see more patients and hopefullygive more time to patients, as well.
SAWYER: I want to turn to someone who thinks we should follow up onwhat we were talking about a while back, namely about, in some way,reducing the vicious cycle of lots of tests, lots of treatment, what'snecessary, what isn't necessary, and saying that somebody has got toenforce this. It's not going to happen if somebody doesn't. And, bythe way, he is James Rohack from Texas, and he is president of the AMA,the American Medical Association.
DR. J. JAMES ROHACK, PRESIDENT, AMERICAN MEDICAL ASSOCIATION: Thank you. Mr. President, clearly, when you spoke to us last week, you said that weentered the medical profession not to be bean counters, not to be paperpushers, but to be healers. And we totally agree.
How are you going to assure the American public that medicaldecisions will still be between the patient and the physician and notsome bureaucracy that will make decisions on cost and not really whatthe patient needs?
GIBSON: Once again, we'll leave that question on the table.
OBAMA: All right.
GIBSON: You answer it when we come back from commercial break. "Prescription for America" will continue.
GIBSON: So, Mr. President, you remember the question.
OBAMA: I do.
Well, first of all, I want to thank the American MedicalAssociation. I did appear before them just last week in Chicago, myhometown, and had a terrific exchange of ideas. And we're continuing towork with all stakeholders -- doctors, nurses, insurers, and obviouslypatients, you name it. Folks out there are interested in seeing thishappen.
The most important thing I can say, James, on this issue is, if youare happy with your plan and you are happy with your doctor, then wedon't want you to have to change. In fact, if we don't do anything, ifthere's inaction, I think that's where the great danger that you loseyour health care exists, because of the cost problems that I alreadytalked about.
So what we're saying is, if you are happy with your plan and yourdoctor, you stick with it. If you don't have insurance, if it's too
much for you to afford, if your employer doesn't provide or you're
self-employed, then we will have what is called an exchange, but you can
also think of it as a marketplace where essentially people can compare
and look at what options are out there.
They'll have a host of different health care plans available, each
with their own physicians network. And you will be able to sign up for
the plan that works for you. We will help people who don't have
insurance get insurance.
Doctors are not going to be working for the government. They're
still going to be working for themselves. They're still going to be
focused on patient care. And in terms of how doctors are reimbursed,
it's going to be the same system that we have now, except we can start
making some changes so that, for example, we're rewarding quality of
outcomes rather than the number of procedures that are done.
And this is true not just for doctors, it's also true for
hospitals. One of the things that we could say to hospitals is, reduce
your readmission rate, which is also often a sign that health outcomes
have not been so good.
And it turns out that hospitals, when they're incentivized, actually
can find ways to do it that, every study shows, does not have adverse
effects on outcomes.
GIBSON: You keep coming back to that point, about, if you like what
you have, you can keep it.
GIBSON: I will return to that subject when we get to the issue of
the public option and whether the government should be in the insuring
But one of the things when we talk about the kinds of changes that
may occur, the elderly are affected. Medicare will be affected.
Twenty-eight percent -- 26-28 percent of money in Medicare is spent in
the last year of life. The elderly are very critically affected.
Just a quick sound bite from a couple of people to lay out the
parameters of the problem.
(BEGIN VIDEO CLIP)
DR. MICHAEL JENSON, MAYO CLINIC: I'm Dr. Michael Jenson
at the Mayo Clinic in Rochester, Minnesota.
I see too many patients who have terminal illnesses or no hope of
recovery who receive weeks or months of intensive care unit treatment,
only to prolong their death. I find this approach very distressing and
the waste of money is appalling.
We just can't afford to provide all treatments to all people.
ROBERT WASSON: My name is Robert Wasson. My mother is 74
years old. She has terminal cancer in the stomach lining that has
spread to the lungs. She deserves to be treated medically to the best
of their ability.
To say it's too expensive is not right. I just don't think you can
put a price tag on quality time with loved ones, especially at the end
of their lives.
(END VIDEO CLIP)
SAWYER: And we have with us a couple of people who really represent
the opposite ends on this spectrum too. I want to talk, if I can, to
Your mother, Hazel...
JANE STURM: Caregiver for 105-year-old mother: Yes.
SAWYER: Hazel Homer (ph), 100 years old and she wanted...
STURM: She's 105 now. Over 105. But at 100 the doctor had said to her, I can't do anything more unless you have a pacemaker. I said, go for it. She said, go for it. But the arrhythmia specialist said, no, it's too old.
Her doctor said, I'm going to make an appointment, because a picture
is worth a thousand words. And when the other arrhythmia specialist saw
her, saw her joy of life and so on, he said, I'm going for it.
So that was over five years ago. My question to you is, outside the
medical criteria for prolonging life for somebody elderly, is there any
consideration that can be given for a certain spirit, a certain joy of
living, quality of life? Or is it just a medical cutoff at a certain age?
OBAMA: Well, first of all, I want to meet your mom.
OBAMA: And I want to find out what's she's eating.
OBAMA: But, look, the first thing for all of us to understand is
that we actually have some -- some choices to make about how we want to
deal with our own end-of-life care.
And that's one of the things I think that we can all promote, and
this is not a big government program. This is something that each of us
individually can do, is to draft and sign a living will so that we're
very clear with our doctors about how we want to approach the end of life.
I don't think that we can make judgments based on peoples' spirit.
That would be a pretty subjective decision to be making. I think we
have to have rules that say that we are going to provide good, quality
care for all people.
GIBSON: But the money may not have been there for her pacemaker or
for your grandmother's hip replacement.
OBAMA: Well, and -- and that's absolutely true. And end-of-life
care is one of the most difficult sets of decisions that we're going to
have to make.
I don't want bureaucracies making those decisions, but understand
that those decisions are already being made in one way or another. If
they're not being made under Medicare and Medicaid, they're being made
by private insurers.
We don't always make those decisions explicitly. We often make
those decisions by just letting people run out of money or making the
deductibles so high or the out-of-pocket expenses so onerous that they
just can't afford the care.
And all we're suggesting -- and we're not going to solve every
difficult problem in terms of end-of-life care. A lot of that is going
to have to be, we as a culture and as a society starting to make better
decisions within our own families and for ourselves.
But what we can do is make sure that at least some of the waste that
exists in the system that's not making anybody's mom better, that is
loading up on additional tests or additional drugs that the evidence
shows is not necessarily going to improve care, that at least we can let
doctors know and your mom know that, you know what? Maybe this isn't
going to help. Maybe you're better off not having the surgery, but
taking the painkiller.
And those kinds of decisions between doctors and patients, and
making sure that our incentives are not preventing those good decision,
and that -- that doctors and hospitals all are aligned for patient care,
that's something we can achieve.
We're not going to solve every single one of these very difficult
decisions at end of life, and ultimately that's going to be between
physicians and patients. But we can make real progress on this front if
we work a little bit harder.
SAWYER: Is that a conversation you could have had with your mom?
STURM: What I wanted to say was, that the arrhythmia
specialist who put the pacemaker in said that it cost Medicare $30,000
at the time. She had been in the hospital two or three times a month
before that, so let's say 20, 30 times being in the hospital, maybe
going to rehab, the cost was so much more. And that's what would have
happened had she not had the pacemaker.
OBAMA: Well, and that's a good example of where -- if we've got
experts who are looking at this, and they are advising doctors across
the board that the pacemaker may ultimately save money, then we
potentially could have done that faster.
I mean, this can cut both ways. The point is, we want to use
science, we want doctors and -- and medical experts to be making
decisions that all too often right now are driven by skewed policies, by
out-dated means of reimbursement, or by insurance companies.
And everybody's families, I think, have had to experience this in
one way or another. That's -- that's the reason we need reform right now.
GIBSON: We're going to take one more commercial break, Mr.
President. When we come back, we're going to get into the issue of
whether or not in a reform measure there should government insurance for
people, because a lot of people are very uncomfortable with that idea.
"Prescription for America" continues.
ANNOUNCER: "Questions for the President: Prescription for America"
continues. Once again from the White House, Charles Gibson and Diane
GIBSON: As I probably could have anticipated, this is running a
little longer than we thought. The president's been nice enough to
stay. He would say that he would stay during your local news, and we
will continue this discussion during the "Nightline" half-hour. And so
we're going to get into that public option and whether there should be
government insurance as part of all of this.
But I do want to get to cost, because, as you know, the
Congressional Budget Office is estimating that this is going to cost
over the next 10 years $1 trillion to $2 trillion. There's all these
estimates. And the question is, can we afford it? And there's a lot of
people who have that question on their mind.
SAWYER: And bringing in Christopher Bean from Maryland.
Christopher Bean, Allint Tech Systems Human Resources Department: Good evening. It's a pleasure to be here and meet you.
BEAN: I do have a -- kind of a two-base question. I'm going
to read it, because I'm very nervous.
In light of this proposed health care reform and national health
care system, I have many concerns. One of them is the big -- is the big
brother fear. How far is government going to go in reference to my
personal life and health care treatments?
And then, secondly, how and who will pay for the national health
OBAMA: Good. Well, look, both are great questions. We've been
sort of circling around your first question, the whole big brother
fear. What kind of insurance, Chris, do you have right now? What kind
of coverage do you have?
BEAN: Blue Cross Blue Shield.
OBAMA: It's a Blue Cross Blue Shield. So if you're happy with your
plan, as I said, you keep it.
Now, there are some restrictions we want to place on insurers.
Pre-existing conditions is a tool that has prevented a lot of people
from either not being able to get insurance or, if they lose their job,
they can't find insurance. We think those policies should end.
So there are going to be some areas where we want to regulate the
insurers a little more. Now, in exchange, they're going to have a
bigger customer pool. And so we think that they may not make as much
profit on every single person that they provide coverage to. On the
other hand, overall, I think they can still be profitable.
In terms of cost, understand that the system is already out of whack
in terms of costs as it is. So if we do nothing, costs are going to
keep on going up 6 percent, 7 percent, 8 percent per year, and
government, businesses and families are all going to find themselves
either losing their health care or paying a lot more out of pocket.
That's going to happen if we do nothing.
What I've said is, let's change the system so that our overall cost
curve starts going down, by investing in a range of things, prevention,
health I.T., et cetera. We will have some upfront costs, and the
estimates, as Charlie has said, have been anywhere from $1 trillion to
But what we've said is, what my administration has said, what I've
said, is that whatever it is that we do, we pay for, so it doesn't add
to our deficit.
Now, we've put forward some specific ways of paying for the health
reform that we talked about. About two-thirds of the cost would be
covered by re-allocating dollars that are already in the health care
system, taxpayers are already paying for it, but it's not going to stuff
that's making you healthier.
So a good example of that -- we spend $177 billion over 10 years on
providing subsidies to insurers. And if we can take that money and use
it to help train young doctors for primary care, to provide more
coverage, to improve prevention and wellness, that's a good way of
spending money that we're already spending.
About a third of the costs will come from new revenue. And so what
I've proposed is, is that we cap the itemized deductions that the top 2
or 3 percent get, people making over 250 a year, me and Charlie, so that
our item -- so that we're itemizing our deductions at the same level at
-- as most middle class families are.
With that additional money, we would have paid for all of the health
care that I'm proposing. So there is a way of paying for this that
doesn't add to the deficit.
And the last point I'll make, it's a big question -- I was trying to
be quick, because Charlie is looking at his watch, the last point is,
all of this money that I just talked about, those are hard dollars. We
know where they are and so we know that this would not add to the deficit.
It doesn't count all of the savings that may come from prevention,
may come from eliminating all of the paperwork and bureaucracy because
we have put forward health IT. It doesn't come from the evidence-based
care and changes in reimbursement that I've already discussed about.
And the reason is, is because the Congressional Budget Office, the
CBO, which sort of polices what our various programs cost, they're not
willing to credit us with those savings. They say, that may be nice,
that may save a lot of money, but we can't be certain.
So we expect that not only are we going to be able to pay for health
care reform in a deficit-neutral way, but that it's also going to
achieve big savings across the system, including in the private sector
where the Congressional Budget Office never gives us any credit.
But if hospitals and doctors are starting to operate in a smarter
way, that's going to help you even if you're not involved in the
government system. That's how we can end up achieving cost. But it
requires all of us making some up-front investments. And I think we can
find a bipartisan way to do that.
SAWYER: Mr. President, we're going to take a break, come back with
a lot more questions about whether the government should be involved in
all of this, who is going to be covered, and not, and how.
We'll be back.
SAWYER: We have a question from Dr. Gail Wilensky, who ran Medicare in the Bush administration. Your question?
Gail Wilensky, Senior Fellow, Project HOPE: I want to go back to how we pay for the expansions. Estimates, as you indicated, probably $1.5 trillion to cover everyone. You mentioned savings in Medicare and Medicaid, $500 billion to $600 billion, from the numbers you've provided. Another $300 billion from additional revenue. That leaves about $300 billion to $600 billion more. What do we do in ways that CBO will count so that we can actually get everybody covered?
GIBSON: And run that down in about 30 seconds.
OBAMA: Look, that's the challenge. And, obviously, there's a
vigorous debate taking place. There are a whole host of ideas, some
that cut across parties. There are people who think that we should tax
benefits -- health care benefits at a certain level, cap the deduction.
There are others who proposed a surcharge on high-income individuals.
There are other cuts that may be obtained that ultimately we could find
Here's my general point, because I know that we're starting to wrap
up. This is not an easy problem, and it's especially not an easy
problem when the economy is going through a difficult phase. You know,
we've taken a body blow to the economy, and families were oftentimes
hurting even before then.
But the one thing I'm absolutely confident about is that, whenever
this country has met a significant challenge to our long-term
well-being, that we ultimately rise up and meet it. And this is one of
those moments where the stars are aligned.
We've got insurers who are interested, doctors who are interested,
nurses, patients. AARP is here, and they've seen some of the potential
benefits. We're actually going to be filling the donut hole. Drug
companies have said that they'd be willing to reduce the cost for
seniors for prescription drugs as part of health care reform.
But we have to have the courage and the willingness to cooperate and
compromise in order to make this happen. And if we do, it's not going
to be a completely smooth ride. There are going to be times over the
next several months where we think health care is dead, it's not going
But if we keep our eye on the prize, and if we recognize that
America's always stood up to these big challenges, and we can't afford
not to act, then I'm absolutely convinced that we can get it done this time.
GIBSON: Mr. President, thanks. We're going to take a
break. Be right back.
GIBSON: So that concludes our primetime special of "Prescription for
America," but your local news is coming up next, and we hope you'll stay
with us. The president is going to stay with us. Our audience stays
with us. And we will have more questions for him about health care
reform during the "Nightline" half-hour.
GIBSON: And we welcome you to this special edition of NIGHTLINE. Just
to tell you where we are, we're in the East Room of the White House with
the president and the 164 invited guests here who represent all
different perspectives on the subject of health care reform.
And we have questions for the president. Call this "Prescription for
America." We had an hour there on "PRIMETIME," earlier, before your
local news, but the president is going to stay with us and we have more
And there are some critical things that we did not get to in that hour.
Most critically of all, in talking about health care reform, this very
controversial subject of whether there needs to be a public option,
whether there needs to be government-run insurance as one of the options
to get more people insured, and for the general nature of health care
Your critics on the Republican side of the Senate Finance Committee
wrote you a letter and said: "At a time when major government programs
like Medicare and Medicaid are already on a path to fiscal insolvency,
creating a brand new program will not only worsen our long-term
financial outlook, but also negatively impact American families who
enjoy private coverage for their insurance."
What do you say to them?
OBAMA: They're wrong.
OBAMA: And so let's just explain as clearly as possible what we're
talking about. What we want to do, as I said before, was set up a health
care exchange, or a marketplace. Essentially giving the American people
the same kind of options that members of Congress do or federal
There is a range of options that are available. Private insurers will
participate. You will be able to do some one-stop shopping and compare
all of the different plans, what kind of benefits they provide, what are
the deductibles, figure out what is best for you.
Now what we've said is, as one option among multiple options, should be
a public option where we set up an insurer that isn't profit-driven,
that can keep administrative costs low, and that can serve as
competition to the private insurers.
Now what -- the argument that has been made has been that somehow the
public option will crowd out private insurers.
GIBSON: It's not a level playing field.
OBAMA: And that's the argument, that it's not a level playing field. And
what we've said is, it wouldn't be a level playing field if the
government can just print money and subsidize that public plan so that
premiums are a lot lower than costs and doctors are getting reimbursed a
lot lower than they do in the private sector. Well, that's true. It also
wouldn't be a very good plan.
But what we've said is that we can set up a public option in which
they're collecting premiums, just like any private insurer, that doctors
are reimbursed at a fair rate, but, because administrative costs are
lower, we are able to keep private insurers honest in terms of the
growth of costs of premiums and deductibles and so forth.
Now, you'll always hear folks say that the free market can do it better,
government can't run anything. And what I say, well, if that's the case,
nobody is going to choose the public option.
So, you know, the private insurers who I think are very confident that
they're providing a good service and a good product to their customers
should feel confident that they can compete with just one other option.
A lot of the objection to the public option idea is not practical. It's
ideological. People don't like the idea of government being involved.
But keep in mind that the two areas where government is involved -- are
involved in health care, Medicare and the V.A., actually there's pretty
high satisfaction among the people who participate.
GIBSON: Well, Diane is here with the head -- with the head of a major
SAWYER: If I could, I'm going to bring in Ron Williams from Aetna, CEO
of Aetna. And if I can reverse the order a little bit, Mr. President,
I'd like to ask a question of him and then let you come in on his answer.
SAWYER: Mr. Williams, Aetna, so take one. An insurance company we hear
all over the company people see their premiums going up 119 percent in
the last several years. They see the profits of the insurance companies
in the billions and billions of dollars. Even in a lean year, they see
profits in the billions of dollars. Is the president right that you need
to be kept honest?
RONALD WILLIAMS, PRESIDENT AND CEO OF AETNA: Well, I would first say I would commend the president for the commitment he's made to really try to get and keep everyone covered. And I think, as a health insurance company, we're committed to that.
In the context of the question that you asked, I think that it's
difficult to compete against a player who's also the person who's
referring the game. And so I think in the context of thinking about a
government plan, what we say is, let's identify the problem we're trying
to solve. Let's work collaboratively with physicians, hospitals, and
other health care professionals, and make certain that we solve the
problem, as opposed to introduce a new competitor who has the rulemaking
ability that government would have.
SAWYER: Mr. President?
OBAMA: Well, I think that...
SAWYER: Premiums going up...
OBAMA: First of all, I want to say that Mr. Walters (sic) has been very
cooperative. We've been having a series of conversations, and I
appreciate the constructive manner in which we've been trying to work
But I just want to make clear that the government, whatever rules it
provides to insurers, a public plan would have to abide by those same
rules. So we're not talking about unlevel -- unequal playing field.
We're talking about a level playing field.
I also want to point out that one of the incentives for private insurers
to get involved in this process is that potentially they're going to
have a whole bunch of new customers, paying customers.
And if we are, as part of health care reform, going to go forward in
providing additional coverage to people who either don't have health
insurance or who are underinsured -- and that's a lot of working people.
I just want to be clear. These are people who are working everyday and
are still finding themselves having a great deal of trouble, and
oftentimes collecting huge amounts of debt.
If we're going to give all these new customers to the insurance
industry, one of the things that we should say is, in return, that we
change some of our practices and at least have some competition so that,
for example, you can't eliminate people for pre-existing conditions, you
can't cherry-pick just the healthiest folks, and a public option is one
tool by which we can do this.
And I think that the insurance companies will still thrive. They've got
terrific leadership. Aetna is a well-managed company, and I'm confident
that your shareholders are going to do well.
GIBSON: Mr. President, there is a lot of doubts about this as to whether
it's a level playing field. The Lewin Group studied this. There's 177
million in this country with private insurance through their employers.
That group estimates, with government insurance, that employers will go
to that because it will be cheaper. And they estimate, the head of the
Lewin Group, I believe, is here, Mr. Sheils -- they estimated that
two-thirds of people would go to the private -- go the public insurance
Let me get you a microphone. Can we get him a microphone, please? Thanks.
JOHN SHEILS, THE LEWIN GROUP: Well, we looked at several different
options. You could design it in several different ways. There was a
particular scenario that people looked at, and that's what got all the
attention. It's one where the premiums would be -- for a family, for
example, would be as much as $2,500 a year less than in the private market.
The reason for it is that they paid under -- under -- they used the
Medicare payment reimbursement methodology, and they paid physicians a
lot less, hospitals a lot less. So the premium came out as much as
$2,500 a family lower in that particular scenario.
That's pretty attractive. We estimate that 70 percent of anybody with
private insurance would -- would make the shift to the public plan.
GIBSON: Which would be millions of people going over to public
insurance. You keep saying, if you have what you like, you can keep it,
but if your employer goes over to the government program, maybe you
can't keep what you have.
OBAMA: First of all, I think it's important to understand -- and I think
the Lewin Group acknowledges this -- that there are a whole series of
ways that we could design this. One of the things that we've said is
that, if you are eligible for your employer plan, then you can't just go
into the public plan, you can't decide that you're already having a
pretty good deal in insurance, and you're just going to dump that,
what's called a firewall.
The other thing we're doing is we're saying to employers, to provide
them a disincentive for just dumping people out of existing plans, is
there's going to be a pay-or-play provision. If you're not providing
health insurance to your employees and you're a large employer, you're
going to have to kick in a certain amount of money because it's not fair
for taxpayers to have to cover your employees, whether it's through a
public plan or through uncompensated care -- essentially sending people
to the emergency room -- which, by the way, adds to all of our premiums
collectively about $1,000 bucks a year.
So we would have -- I think there are some legitimate questions in terms
of how the public option is designed. One thing I have to say, though,
is, it's not an entirely bad thing if, as long as they're reimbursing
doctors in an adequate way, and -- and -- and so not being oppressive on
-- on health care providers, and as long as there are not a whole bunch
of taxpayer subsidies going into a public plan, if the public plan can
do it cheaper and provides good quality care, that's the competition
that we talked about.
I don't think you're going to get a lot of complaints from people if the
deal is a better deal. If it's not a better deal, then people aren't
going to choose it. And -- but what we think is, is that we can set up a
system in which you are expanding choices for individuals as opposed to
GIBSON: All right. We'll take a commercial break. "Nightline" will
continue. Stay with us, more questions for the president.
GIBSON: And we're back. Our special edition of "Nightline" continues.
Mr. President, on this issue of costs, of this entire thing, a lot of
people are concerned that it's going to be so expensive, their taxes are
going to go up. And we have a question on that very subject. Is David
David, where you are? Stand up.
DAVID HATTENFIELD, Cornerstone Baptist Church, Cumberland, MD: Yes, I guess the -- the -- first of all, I'd like to -- just to say it is good to be here this evening.
OBAMA: Thank you, David.
HATTENFIELD: With the -- with the cost of health care, you know,
I'm pretty satisfied with my own plan. It's not everything that it
should be or could be, but I am concerned that -- of the government
taking over health care. And, you know, Social Security isn't -- isn't
doing real well. At least that's what we're being told. And how can we
know that the government is going to be able to handle the cost of
health care? Isn't that going to tax me? Isn't it going to be taxing my
benefits, those kind of things?
OBAMA: Right. Well, look, I think it's a very legitimate question. I
guess that the first point I'd make is, if we don't do anything, costs
are going to go out of control. Nobody disputes this.
Medicare and Medicaid are the single biggest drivers of the federal
deficit and the federal debt by a huge margin. And at the pace at which
they're going up, if we don't do some of the things that we've talked
about tonight, you know, changing how we pay for quality instead of
quantity, making sure that we are investing in prevention, all those
game-changers that I discussed earlier, if we don't do those things,
Medicare and Medicaid are going to be broke, and it will consume all of
the federal budget.
Every program that currently exists under the federal budget, except
defense and entitlements, all that would be swept aside by the cost of
health care if we do nothing. So that's point number one.
Point number two is that a lot of what we're talking about is
reallocating existing health care dollars that are not being spent
wisely. And almost everybody agrees that there is a lot of room for us
to improve how we're spending existing health care dollars.
And point number three. There is going to be a need initially for some
additional revenue. And I talked about our suggestion -- my
administration's suggestion the best way to do that, capping itemized
deductions for people making over $250,000 a year.
But I also believe that if we are doing this right and we're bending the
curve on health care, then you who keeps a private plan will see
reductions in your out-of-pocket costs over time.
So that instead of your health care premiums going up three times your
wages over the next decade, it may only go up by the amount that
inflation goes up generally. And that's real money in your pocket.
That's real savings that would offset any potential increases.
By the way, I suspect that Charlie and I, again, 2-3 percent of the
population, we're the ones who would see our taxes go up a little bit to
pay for that initial outlay.
GIBSON: But let me -- on this tax question, let me get to this issue of
taxing health care benefits.
GIBSON: It isn't -- there is a massive amount of money that employers
pay for health care benefits, and it is not taxed for me or anybody else
in this room. You went after John McCain when he suggested taxing that
money. That we would have to pay taxes on that.
Should we pay taxes on that? A lot of people question whether there is
enough money to pay for all of this.
GIBSON: Are you willing to entertain the idea of taxing health care
OBAMA: Well, I continue to strongly disagree with John McCain's plan
that he presented during the campaign which was to eliminate the
deduction -- let me finish…
GIBSON: But you went after -- you went after him for suggesting that we
tax that money.
OBAMA: I'm about to answer your question, Charlie.
GIBSON: OK, good.
OBAMA: The -- I continue to believe that it would the wrong way to go
for us to eliminate the deduction -- or the exclusion on health care
benefits that essentially taxes current benefits.
What is being discussed in Congress right now is capping those -- that
deduction or that exclusion at a certain level. I continue to believe
that's not the best way to do it, because I think that what you would
see, certainly if you eliminate it completely, essentially employers
would stop providing health insurance.
And then we would really have to have either a public plan or what John
McCain was proposing, everybody just gets that money back in wages and
then -- or tax credits and you go out and you shop by yourself.
The problem is that the amount of money you're getting back is not going
to be the same as the cost of an average insurance plan, especially if
you're not in a pool. What's being -- that's not what is being discussed
right now in Congress.
They're saying, at a certain level, whether it's $13,000 or $17,000 a
year, which is what they consider to be a high-end or a "Cadillac plan,"
maybe your deduction would phase out. I continue to believe that the
better way for us to fund this is through the capping of the itemized
But I think there are people, you know, in good faith who are saying a
cap would at least prevent these "Cadillac plans" that end up having
people over-utilizing the system. That's a debate that is taking place
in Congress right now.
I'm pushing my idea, other folks are pushing their ideas. There is going
to have to be some compromise at the end of the day.
GIBSON: All right. Mr. President, we'll take another break. NIGHTLINE
continues. Stay with us.
SAWYER: One quick question, if we can here, Charlie. Marissa Milton, skeptical?
MARISSA MILTON, HR Policy Association: A little skeptical on cost, Mr. President. Other industrialized nations provide coverage for all of their residents, they
have higher quality care, and they do so spending about less than half
of what we spend on health care now.
So there's an argument that could be made that we actually don't need to
spend any new money to fix the system if we're willing to make some
tough decisions. Could you comment on that and maybe exploring that as
OBAMA: Well, you're absolutely right that we spend at least 50 percent
more than any other advanced country, and we don't have better outcomes,
in terms of infant mortality, longevity, all those various measures of
Now, a lot of those other countries employ a different system than we
do. Not all of them, by the way, use a -- socialized medicine, as I
think the -- the British National Health Service is called. Some of them
have what would be considered -- almost all of them have what would be
considered a single-payer system, in which the government essentially
operates a Medicare for all, even though doctors and health care
providers are still separate.
The problem is, is that we have an employer-based system that has grown
up over decades. For us to completely change our system, root and
branch, would be hugely disruptive and I think would end up resulting in
people having to completely change their doctors, their health care
providers in a way that I'm not prepared to go.
This is one-sixth of our economy. I think that we can build on what
works, fix what's broken, and still save some substantial money.
SAWYER: Gary -- Gary Cloutier, who is a body shop owner.
GARY CLOUTIER, UNINSURED SMALL BUSINESS OWNER: Yes, body shop owner from Westfield, Massachusetts, Cloot's Auto Body. Got to give myself a plug.
OBAMA: There you go.
CLOUTIER: And I don't have insurance. I'm one of those 46 million
that has none at all. Under Massachusetts policy, I make too much money
and I don't qualify, so I'm on the outside looking in. What are you
going to do for people like me so that we don't fall through the cracks
and we're able to get insurance like everybody else?
OBAMA: Well, I think the self-employed are a huge example, and that's a
growing part of our population. And that's a huge portion of the people
who are having a very difficult time getting health insurance, partly
because, if you're not part of a big pool, you just can't get a good
deal. It ends up being really expensive.
That's why we want to set up these exchanges, because for a person like
you who's self-employed, doesn't have health insurance, for you to be
part of this exchange, this marketplace, along with millions of others,
suddenly you've got a little bit of market clout. Private insurers are
going to want your business, and that means that you can negotiate for a
If we've got a public option in there, then that's also an alternative.
And one of the things that we're going to need to do is to provide some
subsidies for folks who just can't afford it even when the option is
provided to them.
That's where some of the new money is going to come in, is to make sure
that people who don't have health insurance are able to get it without
taking on huge amounts of debt.
GIBSON: Dr. Tim Johnson, our medical editor, we started this with you,
outlining the parameters of this. An observation?
JOHNSON: An observation would be, if you're successful in getting rid of
some of that 30 percent of unnecessary care, you're going to dislocate a
lot of people. Now, some of them are criminals committing fraud; they
ought to go to jail. But a lot of them are real people with real jobs.
Why not right now start talking about retraining these people for
primary care jobs, nurse practitioners, physician assistants? I hear no
talk about that.
OBAMA: Well, I think you make a -- a reasonable point that, if you're
going to change the health care system over time, then to be very
specific, the amount of person power that goes into billing,
administration, all the things that we hate about the health care
system, even though those are wonderful people who are doing great work,
they're over time hopefully going to be moving into the actually
providing care side of the health care industry as opposed to the
bean-counting side of the health care industry.
Keep in mind, though, that this is -- our goal here is to over time
change the system, over time reduce costs, over time transition those
folks into the -- the health care side of it. We already mentioned that
we still have a nurse shortage out there. We still have a shortage of
people who are providing primary care. People who are already in the
health care system, I think, naturally would gravitate towards that.
And the last point I would make is, we've got an aging population, so we
know that health care is still going to be a growth industry. And that's
not an entirely bad thing. As societies get older, we spend a certain
larger portion of our overall income on health care.
And that's OK. We just don't want to spend it badly and in a way that
bankrupts the entire economy. And that's why we need the changes that
GIBSON: Mr. President, we want to thank for joining us this evening,
both for the earlier hour and for this half-hour of "Nightline." As we
mentioned at the beginning, I think this is a topic that is going to be
discussed in every living room over every kitchen table, not only in the
Congress, but mostly in the living rooms and in the kitchens of America,
and that probably is where the decisions overall will be made.
Can we support this? Are we for this? Are we certain that we'll have the
care we need? And are we certain that this country can pay for it in a
time when we don't have a lot of money?
OBAMA: The answers are "yes" to all of that. And if the American people
get behind this, this is going to happen.
GIBSON: All right, Mr. President, I thank you for being with us. Thanks
OBAMA: Thank you so much. Enjoyed it. Thank you.
GIBSON: And we thank you for being with us for this edition of
"Nightline." Take care, and good night.